2.0 Analysis 2.1 Operators - Level of Training Skilled, proficient and knowledgeable operators are necessary to operate machinery safely. Personnel were not allowed to operate land-based equipment or machinery unless they were certificated after satisfactory completion of approved training courses. The vessel differed from other equipment in that respect even though she also had to be operated safely. Although the operator had several years of experience in operating the vessel and some background in commercial fishing, his level of training and knowledge was not adequate to recognize the inherent dangers of operating the vessel with free-surface water on the deck. The same was true of the vessel's other operators. The operators had reported the tendency of the vessel to capsize before this accident, but no action was taken by their employer to rectify the situation. This indicates that either the management of the company did not have the level of expertise necessary to recognize the dangers of operating the vessel in such a condition or chose to ignore them. Because the vessel's operating manual had been misplaced ashore, vital information on safe working practices was not available to the vessel's management or operators. The manual outlines the safe working practices necessary to avert such an accident. 2.2 Bow Ramp Seal A flexible gasket is required to maintain the watertight integrity of the bow ramp. Without the flexible seal, the effective freeboard of the vessel is at the same level as the deck; in this case, there was no effective freeboard at all when the vessel was loaded. The operating manual stresses the importance of bow ramp gasket integrity; however, Fletcher Challenge Canada was not aware of and did not ensure that the vessel's operators were aware of the gasket's importance. 2.3 Effect of Adding the Sponson Protection Shoes The addition of the fibreglass wear surfaces to the outer lower hull in way of the beaching area aggravated the lack of freeboard because the shoes were not mounted fair with the hull. The shoes would thus increase the size of the bow wave and force more water through the ramp/hull gap. The shoes added weight to the forepart of the vessel and also acted as water scoops which prevented the bow from lifting when making headway. The drag on the vessel would have increased considerably and generally degraded loaded-condition performance. 2.4 Propensity to List to Starboard The reasons for the vessel's tendency to always list to starboard when water was on deck were not readily apparent. The underwater portion of the hull is clear of any obstruction that may cause this. The hull is not deformed, racked or twisted in a way that would produce this tendency. Some possible reasons are advanced below. The sponson protection shoes attached to the hull are not fair with the hull and exhibit different degrees of damage as a result of beachings. While it is not easily measurable, it is possible that the drag caused by the starboard shoe could be greater than that of the one to port, thereby giving a turning moment to the hull. The tube socket fitting on the starboard inboard bulwark is secured to an internal hull box member for strength. This attachment area is reinforced and intrudes into the water channel that allows drainage aft of any water on deck. The anchor rope is coiled down in the channel as well. The channel is not blocked completely as a drainage slot exists to allow small quantities of water to pass through. However, this arrangement was never designed to pass the large amount of water that came through the ramp gap. The resulting accumulation of water trying to pass through and around this area would cause a list and the resultant free-surface effect would reduce the vessel's stability. The added weight would also cause bodily sinkage, putting the bow, and therefore the gap, further under water and forcing more water on to the deck. Separately, the above factors may not be significant, yet their synergism may exceed the sum of their individual effects. 2.5 Industrial Health and Safety Considerations Contrary to what the employees believed, the CSA applied to the vessel only in respect of the carriage of LSE and to the lights that the vessel was required to carry. The vessel met or exceeded these requirements; however, due to her small tonnage, there was no requirement that the vessel be inspected by the CCG Ship Safety Branch. 2.6 Vehicle Weights No explanation was given why the weights of the vehicles to be carried by the vessel were not determined and prominently displayed on the vehicles. The company was aware of the maximum weight to be carried on the vessel and had posted this weight in the wheel-house before the occurrence. 2.7 Familiarity with Life-saving Equipment The operator was not required to have formal marine emergencies training. The difficulties he experienced with the LSE could have had serious consequences. The operator did not recognize the parachute flares in the liferaft canister. As a result, he did not use the best means of attracting attention. 2.8 Safety Culture Logging is one of the most dangerous industries in British Columbia. Over the last 15 years, there have been almost 500 fatalities, and over 4,700 loggers have been awarded permanent disability compensation. As a result, the industry has developed programs to address safety issues and reduce the accident rate. These safety programs were, however, not extended to the operation of the landing craft. There was no designated operator, no formal training, and no response to equipment and operational deficiencies. There was also a lack of understanding of the applicability of regulatory standards and a failure to recognize the inherent dangers of operating the vessel. The safety system in place was either not working or failed to appreciate the marine aspects at this logging operation. 3.0 Conclusions 3.1 Findings The damaged and ineffective ramp/hull seal allowed water on deck and reduced the vessel's effective freeboard to the same level as the deck. The vessel's initial transverse stability was reduced by the free-surface effect of the water on deck. The vessel had significant weight added aft as a result of changes to the original design. When the vessel was not carrying cargo, the freeing ports aft were partly underwater and allowed water on deck. The vessel had nearly capsized on several occasions before this occurrence. The vessel's operators and managers were not sufficiently knowledgeable to recognize that the effect of allowing the vessel to operate with a damaged ramp/hull seal was to seriously compromise the vessel's stability. The vessel's operations manual was not made available to the operators or their immediate supervisors. None of the operators were required to have formal marine emergencies training. Supervisory personnel did not act on unsafe condition reports by the vessel's operators stating that the vessel had a tendency to list suddenly when water was on deck. The weight of the vehicle on board at the time of the occurrence was approximately 0.3 tonne more than the maximum weight recommended by published company policy. The weight of the vehicles transported on the day of the occurrence was not displayed on the vehicles nor was the weight of the vehicles accurately known. Vehicles were not secured to the deck because of the short travel distance involved. Although not licensed to do so, the vessel was used to transport personnel. 3.2 Causes The vessel capsized because of a loss of initial transverse stability due to the free-surface effect of water accumulating on deck. The water accumulation was caused primarily by the deteriorated condition of the bow ramp seal. The fact that the vessel's operators and managers were not sufficiently knowledgeable to recognize that the ineffective ramp/hull seal seriously compromised the vessel's stability, and that no action was taken on unsafe condition reports made by the vessel's operators following previous near-capsizings contributed to this accident. 4.0 Safety Action 4.1 Action Taken 4.1.1 Seaworthiness In 1993, as a result of this occurrence, an independent naval architect conducted an inclining experiment on the vessel on behalf of the owners. The TSB also conducted running trials and evaluated the results of the inclining experiment. The Canadian Coast Guard (CCG) and the vessel owners were apprised of the poor physical condition of the gasket material forming the watertight joint between the ramp and the hull of the landing craft, and of the adverse consequence that the accumulation and free movement of water on the loading deck may have on the vessel's effective freeboard and transverse stability. The CROWN FOREST 72-68 was subsequently taken out of service. 4.1.2 Additional Follow-on Actions Subsequent to a Coroner's inquest on this accident, the owners of the CROWN FOREST 72-68 indicated that the following safety measures had been taken: The company safety committee tours the vessels in use every month to identify safety concerns and deficiencies; The International Woodworkers of Canada and Forest Industrial Relations Members Companies have signed an agreement to establish a Joint Committee to develop procedures, equipment standards, and training for the operation of crew boats and barges carrying less than 12 passengers; Emergency procedures have been reviewed with respect to radio communication, requests for diver assistance, and first aid in the workplace; Management and operational personnel within the company, as well as other operators who have purchased similar craft from the company, have been made aware of the potential conditions leading to vessel instability; and The CROWN FOREST 72-68 was taken out of service and the replacement barge was upgraded to meet CCG stability standards. Typical loading information for large and small equipment was also provided. 4.1.3 Safe Working Practices In 1993, the Workers' Compensation Board of British Columbia (W.C.B. of B.C.) published a poster (Logging 93-08) to advise workers in the logging industry of the dangers associated with the operation of small landing craft. The poster calls for the employer to provide written procedures on safe work practices for workers under their direction and control, and to ensure that machinery and equipment are safe. It also reminds workers that a special inspection must be made when there is a malfunction of machinery or equipment. 4.1.4 Marine Emergency Duties (MED) Training The TSB brought the need for training in the use of life-saving equipment on board vessels to the attention of the CCG and of the owners of the CROWN FOREST 72-68. The CCG regional office was notified to advise the owners of the landing craft of the content of Ship Safety Bulletin (SSB) No. 10/88 which, inter alia, strongly recommends that all members of the ship's crew complete the Basic Safety Course, Level A1, MED training. In February 1995, in its SSB No. 6/95 on MED training, the CCG republished and updated issues dealing with MED training previously developed in 1988. The SSB provides general safety advice to industry respecting on-board safety familiarization training to prepare the crew for dealing with emergencies and to reinforce skills for those who have not received MED training. The CCG has also indicated that, although current regulations do not require MED training for personnel of uninspected vessels, proposed amendments to the crewing regulations will require basic MED training for all persons on ships over five gross tons. The responsibility for MED training of uncertificated personnel of vessels not covered by these regulations rests with the owners and masters of these vessels. 4.2 Action Required 4.2.1 Operator Training and Operating Guidelines Personnel operating the CROWN FOREST 72-68 reported that water was regularly seen on deck when the vessel was under way, and that the vessel had developed a starboard list when water was on deck. No one could recall when the bow seal was last intact. The vessel's operators and managers were not sufficiently knowledgeable about vessel stability to recognize that having water on the deck constituted a serious hazard. Small landing craft used to ferry machinery and vehicles, like the CROWN FOREST 72-68, are not regulated or required to be inspected under the Canada Shipping Act (CSA). Furthermore, there are no training and certification requirements for personnel to operate such craft. In the case of the CROWN FOREST 72-68, trained personnel with a knowledge of the vessel's stability and of free-surface effect would have been able to recognize the risks associated with operating the craft under such conditions. Reportedly, there are more than 70 similar small landing craft being used on the West Coast of Canada, many of these in remote areas where emergency assistance may be limited. Furthermore, the craft are most likely being operated by personnel not formally trained in marine operations, including the deployment and use of life-saving equipment. The Board recognizes the initiative taken by the Forest Industrial Relations Members Companies and the International Woodworkers of Canada to develop procedures and training for the operation of craft carrying less than 12 passengers. The Board applauds this action; yet, it feels that the training of personnel and the development of procedures for the handling of vessels should benefit from the input of experts in the marine discipline. The CCG has this expertise. Properly developed and implemented training and procedures could go a long way to enhancing safety in the operation of unregulated small craft, such as the CROWN FOREST 72-68. Furthermore, as evidenced by this occurrence, the owners/operators of unregulated craft may not be aware of conditions, such as the poor condition of the watertight seals, that could be potentially hazardous to the seaworthiness of these craft. The Board is concerned that despite efforts to enhance the knowledge and skills of the operators of these craft, a lack of proper procedures and guidelines on maintenance of both the craft and life-saving equipment could still jeopardize safety. Therefore, the Board recommends that: The Department of Transport, in conjunction with small landing craft owners/operators, develop training programs and guidelines for the operation and maintenance of these craft.